Graphics and Icons for Healthcare with a Focus on Cultural Appropriateness, Diversity, and Inclusion

Abstract

This chapter describes a project to re-work two existing posters used in Emergency Departments across Queensland. The posters depicted how to provide a urine sample, using both text and graphics. After user testing, the Princess Alexandra Hospital worked with the QUT Design Lab to redevelop the two posters (male and female) into one that used gestural drawing (rather than graphically explicit images) and specific colours to make the urine sample collection process simpler for all consumers.

Imagine you are entering into a health care facility in an unfamiliar city where the written language is incomprehensible to you. How do you navigate your way through the corridors or read the instructions on the healthcare forms? A 2010 Universal Symbols in Healthcare study explains that: “Today, one of the most important issues facing health care administrators is providing services to Limited English Proficiency (LEP) populations. Helping them navigate complex health care facilities is a key objective” [1, p. 12]. Combining text and visual methods of communication in health communication and processes can increase awareness and can assist patients and practitioners to better navigate complex systems. According to McNicol and Leamy [2, p. 268], “The representation of medical practices or conditions in comics is not new, but since the turn of the millennium there has been growing interest in graphic illness narratives, often known as graphic medicine or graphic pathologies.” As such the way that instructions for testing and health processes are represented visually can have great impact on uptake and effectiveness in healthcare.

However, the importance of these images and icons is often not well understood, and great care and consideration needs to be taken in crafting images that respond to cultural sensitivities and are inclusive. With diverse populations, cultural taboos and misrepresentations need to be considered in any graphic solution for healthcare application. A 2014 Lancet Commission on Culture and Health [3, p. viii] argued that “the systematic neglect of culture in health and health care is the single biggest barrier to the advancement of the highest standard of health worldwide.” This chapter reviews the history of graphic medical representations and icons. In addition to being useful for individuals with LEP, we discuss how graphic representations of medical practices can be applied to ensure cultural appropriateness and diversity, using a case study of urine collection posters.

1 A History of Medical Graphics and Icons

Humans are visual learners by nature. Visual information is much more easily digested and retained. In fact, it is 60,000 times faster for our brains to process visuals over text. As text is processed sequentially, it takes around 60 seconds for a human brain to understand 200–250 words, whereas we only need a millisecond to understand an image. This also impacts retention—humans only remember about 20% of what they read but this goes up exponentially to 42% when visual content is present [4]. Not only does visual content help us to understand, it also helps with engagement. Therefore, global advertising agencies are paid large amounts to try to find catchy visuals and colours for products and services, as visual content increases engagement by 180% [4]. As such, use of icons, illustrations, and visuals in medical facilities, education, and practices can be a very effective communication method.

Illustrations have been used for centuries to explain and understand complex elements of the body and human anatomy. According to McNicol and Leamy [2, p. 268], “The representation of medical practices or conditions in comics is not new, but since the turn of the millennium there has been growing interest in graphic illness narratives, often known as graphic medicine or graphic pathologies.” Visual representation of medical practices have been found in artifacts from ancient Egypt, on bamboo and silk artifacts from ancient China, on the clay vessels and temples of the ancient Greeks, and in many other mediums throughout the ancient world. These ancient representations are stylised interpretations of the human body as an understanding of anatomy in early societies was minimal because dissection of the human body, was forbidden [5, p. 85]. Realism, and a more-in-depth understanding of human organs and systems, came about in Renaissance Europe. According to Hajar [5, p. 90] “[in the Renaissance] It was not unusual for artists and physicians to collaborate in producing an artistic and scientific work. Artists were interested in the study of proportion; scientists were interested in visualizing the anatomical relationships of various organs as well as depicting their function to understand and promote a particular theory. The symbiotic artist/physician interaction was extremely useful in advancing art and science.”

Illustration is still a very important tool in visualising simple to complex medical systems, processes, or procedures. As Hajar [5, p.84] explains: “A graphic representation of any medical subject is a very effective tool in communicating medical knowledge. Medical students depend on illustration to learn anatomical facts and details that may be too subtle for the written or spoken word. Oftentimes, an illustration transmits the pertinent, useful, and important information much more effectively than words. They ‘tell a story’ through their drawings.” Therefore, the use of illustrations and visuals are essential tools in the healthcare industry. They can bring both simple and complex processes and procedures to life, and can be widely distributed for use in global applications.

1.1 Universal Symbols in Medical Graphics

Pictograms are a form of visual language that have been used since ancient times to represent complex messages visually. The first instance of visual language is Cuneiform, discovered on clay tablets dating back to the thirty-second century BCE. In Cuneiform, the simplification of representative symbols enabled a connection between real things and symbols of things [6]. Universal symbols evolved from this concept of picture language, and, in 1936, Otto Neurath together with Rudolf Carnap and Charles W. Morris, formalised a system of symbols that were used and understood as an international visual language. The Isotype (International System of Typographic Picture Education) system remains the standard for not only international diagrams and graphics, but also text and illustrations used in public [7].

The 2010 Hablamos Juntos (HJ) project drew from the Isotype system and applied the symbol testing method recommended by the International Organization for Standardization (ISO) to create a standardised system of medical graphics. Over a period of three-years they carried out a number of studies in U.S. hospitals to create a system of 54 common healthcare symbols. The 54 symbols are broken up into categories: 12 belong to the service category of administration and medical personnel, 32 are categorised as treatment facilities and departments, and the remaining 10 are medical imaging services, such as X-ray examination [1, p. 24]. Interviews undertaken during the 3 years of research for the Hablamos Juntos project uncovered that both English-speaking and non-English-speaking users believed that the graphic symbol set created for the project is “significantly more readable and more understandable than words. Additionally, over 80% of medical personnel interviewed thought that this system helped relieve their workload with regard to giving hospital visitors instructions” [8, p. 19].

Many universal symbols in the HJ model, such as the stethoscope, relate directly to tools of the trade, however a history of more abstract symbols such as The Cadueus and the Red Cross give evidence of abstract symbols related to complex historical and cultural symbolism. The Cadueus is a universal symbol used globally in the medical profession to represent doctors, healthcare facilities, medical insurance agencies and global healthcare organisations such as the WHO. Dating back to 1400 BC, it is based on an image of the ‘Rod of Asclepius;’ a staff with one snake entwined. In Greek mythology, Asclepius is the god of healing and medicine, and was represented as carrying a staff or ‘rod.’ The use of a snake as a symbol of health dates to ancient Egyptian culture. Based on this historic understanding, snakes were associated with health treatments and used in ancient Greece for healthcare procedures and rituals [9].

One of the most internationally recognized medical symbols, the Red Cross, is used globally to identify nonpartisan medical services. The Red Cross is used generally as a universal symbol for ‘Medical services.’ The symbol originates from 1859 when a Swiss entrepreneur named Jean Henri Dunant (1828–1910) witnessed a horrible battle between France and Sardinia. He called for an international non-partisan group that would attend to the wounded regardless of their affiliations. Subsequently, the Geneva Society for Public Welfare was founded and adopted the symbol of the Red Cross (as used on the Swiss flag). Their name later changed to the International Committee of the Red Cross. A red cross on a white background was eventually designated as the medical symbol to be used for all non-partisan medical services [10].

Universal symbols, whether literal or abstract, therefore need to employ a simple set of visuals with an emphasis on clarity, readability, and ease of use. In his Thoughts on Design, Paul Rand explains: “Visual communications of any kind, whether persuasive or informative, from billboards to birth announcements, should be seen as the embodiment of form and function: the integration of the beautiful and the useful” [11, p. 9]. Illustrations and visual symbols assist those who speak different languages and those with limited literacy to navigate the healthcare landscape. However, the cultural implications of these systems should still be considered.

1.2 Cross-Cultural Understanding of Graphic Images and Information

In an increasingly globalised healthcare sector, it is very important to understand the cultural nuances and bias in visuals, and to create representations that are sensitive to these nuances. Awareness of cultural contexts such as socioeconomic status, environmental conditions, age, gender, religion, sexual orientation, and level of education are all essential in creating an effective healthcare service model in a multicultural society such as Australia. “Our experiences of health and well-being are fundamentally influenced by the cultural contexts from which we make meaning,” explain Napier et al. [3, p. xi].

“Despite what appears to be a cross-cultural ability to recognize objects depicted in pictures, the visual content of an illustration is frequently a vehicle to communicate a more complex meaning or intention. Unlike the subject content of the picture, this intended meaning may often be misunderstood or unrecognized by the viewer” [12, p. 20]. In a study of the effectiveness of the HJ system in Taiwanese hospitals, researchers found that some of the symbols presented cultural nuances that were not apparent in other cultures. In the study it was found that only 12 of the 53 symbols were able to be understood without modification. And, in the case of symbols that included gynaecology and obstetrics, they were deemed culturally inappropriate and needed to be completely redesigned. Joy Lo et al. [13, p. 133] advise that “Good healthcare symbol designs should aim at enhancing the effects of wayfinding system to avoid causing patients to have unpleasant thoughts. Designers should carefully evaluate the indexical and symbolic meaning of graphic symbols.”

“Medical imaging is an invaluable method of conveying information about diseases and pathologic conditions” [14, p. 90.] However, when someone cannot picture themselves in an image, they are not as likely to take up the instructions presented. “Racial bias can distort clinical decision-making and directly impact the daily experience of patients as well as the quality of the care they receive,” explains Massie et al. [14, p. 88]. The Massie et al. [14] study, on race and visual representation in medical imaging, found that that there is lack of diversity in medical images and a significant bias towards a use of Caucasian figures in medical illustrations. In various medical images representing a range of medical fields and geographic regions, Massie et al. [14, p. 90] found that only 18% of images depicted non-white skin tone and there was considerable heterogeneity in the percentage of non-white medical images published from different geographic regions.

In 2017, Nama et al. [15] found that LGBT individuals may avoid seeking medical care, and generally receive poorer healthcare, due to discrimination or perceived discrimination in the healthcare environment. They also explain that transgender individuals may avoid seeking medical care because of their trans-status. Medical forms and graphics can have a negative effect on the LGBT population due to representation of gender. According to the National LGBT Health Education Centre [16], “Forms that use images to document pain or areas of concern should make sure those images are gender neutral. Forms could also employ the use of diagrams not having a human outline, such as quadrants. Images that have a specific gender may limit patients from identifying certain medical issues. For example, male/transgender male patients obtaining a breast screening would need a non-female illustration to document/locate the area of interest.”

This literature shows that care and consideration is critical in the creation of any type of healthcare graphic, particularly in the case of a multicultural health care facility. In the following case study, we document a recent project for a public hospital system and how the illustrations, universal symbols, and text improved upon an existing system by considering and applying principles of inclusion, equity, and access.

2 Case Study: Innovating Healthcare Design for Diversity and Inclusion

2.1 Introduction

Have you ever had to provide a urine sample for the doctor? Recent research in a Brisbane Emergency Department found that nearly half—41.5%—of all midstream urine samples collected from women were contaminated. While contamination rates vary by site, institution, collection, storage, and transport, poor patient technique—due to inadequate instructions—is a key reason for contamination.

Midstream urine samples are frequently collected from patients in Emergency Departments (EDs) for their diagnostic use. Although a relatively simple and cost-effective examination, research collected across EDs has demonstrated that up to 50% of patient-collected urine samples may be contaminated with bacterial flora [17, 18, p. 3], with higher contamination rates typically found in women [19]. Urine samples are the most commonly used diagnostic tool within EDs [20], however the bustling surroundings of an ED naturally create obstacles to ensuring that urine samples are containment-free.

Research from a range of sources [18, 21, 22] indicates that a contaminated urine sample can contribute to:

• diagnostic ambiguity or incorrect diagnosis

• inappropriate treatment

• prolonged time for diagnosis and treatment

• poorer patient outcomes, including increased anxiety

• increased antibiotic misuse and resistance

• increased cost (for repeat testing).

Given the sizable number of these examinations performed, reducing contamination rates presents an opportunity to make substantial savings in terms of cost and staff time [22].

In a 2016 pilot study performed by The Princess Alexandra Hospital (PAH), the ED achieved a 15% reduction in contaminated mid-stream urine samples by introducing step-by-step illustrative charts to guide patients on the correct methods for uncontaminated urine collection [23, pp. 921–925]. The success of the charts was expedited into practice, and submitted to the Clinical Excellence Queensland (CEQ) team at Queensland Health (QH) under the PROV-ED (Promoting value-based care in EDs) project, to be distributed for use across all QH EDs.

3 Project Overview

Eley and colleagues [23] from the PAH developed and tested two sets of graphical illustrations to simply explain the urine collection process to male and female patients, with this intervention reducing contamination rates from 40% to 25%. These graphics were disseminated via a leaflet provided to patients; however subsequent implementation was via posters on the back of toilet cubicle doors.

However, when the CEQ-led PROV-ED Project started to explore rolling these posters out to other emergency departments, initial feedback from staff and consumers was that the original designs were overly graphic, especially for use with children and consumers from different cultural contexts (see Fig. 1).

Fig. 1

Original Male Urine Collection Instructions

The Design Lab at Queensland University of Technology (QUT) was tasked with redesigning the two (male and female) posters to address the concerns of staff and consumers. This initiative between the PAH ED and QUT Design Lab was given the acronym RedUCE—‘Reducing Urine Contamination in Emergency’.

4 Design Intervention

The team explored several options to improve the experience of urine collection—from an infographic to disrupting the process and designing a different container for urine collection, to developing animations that turned urine collection into a game for children. In the end, we settled on redesigning and simplifying the poster, using a gestural drawing approach (a loose form of sketching that expresses movement by capturing basic form). We combined what had been separate posters for men and women into one poster, and reduced the number of steps, to further simplify the process.

The design elements of this project were largely led by designer and Research Assistant Zoe Ryan, who is a PhD candidate at QUT and works within the Design Lab. Zoe works on a foundation of ‘design thinking’ that aligns with the QUT Design Lab’s focus on a human-centered design methodology. Both approaches enable researchers to understand the complexities of the end user, allowing designers to gain further insight to meet a user’s overall social wellbeing at a physical, intellectual, and emotional level [24,25,26].

Zoe explains their overall design process for the REDUCE project in the following reflective discussion.

5 Discussion

As a researcher focused on a disruptive design process, I (ZG) work to dismantle the systems that underpin contemporary design constructs that we are unknowingly conditioned to. Applying my own methods begins with understanding the needs and scope of a project. In a professional capacity, this begins with an initial meeting with clients to build a relationship that fosters a space for ongoing discussions, engage with the subject matter by asking questions, and request any relevant material needed to further research the brief.

The first meeting with the PROV-ED team enabled me to immerse myself into the realm of Emergency Departments, the nuances of medical practices, and the dimensionality of urine collection. Listening to the requirements of the posters’ redesign, I was confident in my personal and professional experience in the LGBTQI+ space and my knowledge of gender, cultural, and social diversity, and I was immediately drawn to the project and its outcomes.

At the end of the meeting our discussions turned to design options and various interventions that would be appropriate for the project. We identified the following requirements for the RedUCE project:

• 1. Minimising the confrontational nature of the graphics while ensuring they fulfil the intended purpose—i.e., to provide clear, easy to follow instructions on how to collect a midstream urine sample to avoid contamination.

• 2. Ensuring graphics are widely applicable to different demographic groups, considering factors such as age, gender, ethnicity, literacy, and cultural or religious differences.

• 3. Be suitable for both adult and paediatric use (anyone who is ‘toilet trained’).

• 4. Ability to be used in different modalities e.g., posters, leaflets etc.

• 5. Include an opportunity or avenue to clarify with staff or ask questions.

The final graphics were trialled by the PAH ED and assessed on their effectiveness, with intention to be reproduced and rolled out to all QH EDs.

6 Design Process

Following on from our ongoing meetings with the PROV-ED team, we explored several options to improve the overall experience of urine collection—from an infographic, to reinventing the process and designing a different container for urine collection, to developing animations that turned urine collection into a game for children. The consensus from the PROV-ED team and The Design Lab was to redesign and streamline the poster design in consideration of the project aims and objectives, with the opportunity to revisit these ideas at a later date if the PROV-ED team wished to do so.

The challenge to create a visually appealing and cohesive design relied upon a combination of theoretical design knowledge, aesthetic considerations, and practical decisions based on academic research and studies to empathise with and understand the needs our target audience. Dividing the visual design choices into a range of categories allowed me to foreshadow when to apply known design principles and when to consult academic literature for more guidance. This strategy permitted a space for ongoing research to take place to make informed decisions within the next stages of the design thinking ideation, prototyping, and testing to take place [27].

7 Poster Layout

First and foremost, the decision was made to combine what had been two separate posters for both sexes (men and women) into one poster, and reduce the number of steps, to further simplify the process and streamline the design. Taking direction from the PROV-ED team on what elements were required within the redesign, I elected to change the orientation of the poster to a portrait format gave a more natural flow and structure to the design, and for ease of display upon a toilet door.

This structure was achieved by creating grids, using the basic design principles of balance, symmetry, and repetition [28]. This sectioning generated a sense of hierarchy by experimenting with spatial allocation that would emphasise the most important information such as the title, boxes for the steps, any additional information needed such as logos and contacts.

The steps of the original poster were reduced from 18 in total (9 for each poster), keeping the first step of guiding the user to wash their hands and then restructured as follows. From step two onward the new poster is broken into two sections adjacent to each other that focus on the two different protocols for each represented sex—male and female. Within these individual sections, three primary steps [2,3,4] for each sex have been identified by the studies conducted by Eley and colleagues [23] as being crucial to the reduction of mid-stream urine contamination. Steps five and six then return to the same overarching format as the first, directing users to complete the collection sample by finishing urination, screwing the lid onto the container, and washing their hands again.

8 Typography

The typeface chosen for the poster design was Myriad Pro, a humanist sans-serif typeface designed by Robert Slimbach and Carol Twombly, with Fred Brady and Christopher Slye, for Adobe Systems [29, 30].

Overall, Myriad Pro is a well-designed and versatile typeface that has become popular in both print and digital media. Its modern and neutral appearance make it highly legible across a range of environment settings [31]. With its range of weights and styles, it is a popular choice for branding, advertising, and user interface design [28, 29].

It is available for both personal and commercial use through Adobe (see Fig. 2 below).

9 The Myriad Font

Fig. 2

Myriad Pro Example (top), and Final colours chosen for the poster layout (bottom)

10 Colour Palette

It is well documented that colours have psychological and cultural associations that can affect the emotions and moods of an individual [28, 32, 33]. However, as Dabner et al. [28] write, “While color associations are highly subjective, despite local differences, colors and hues may have some universal characteristics.” (p. 99). Combining various studies into colour phenomenon provided a deeper understanding into how I can considerately design for larger demographic groups in respect to age, gender, ethnicity, and cultural or religious differences [31, 34,35,36].

However, with the poster needing to suit the look and feel of the medical space, I had to do research into the existing Queensland Health (QH) directives on design trends, and cross referenced them to a list of colours that would be appropriate for our audience, resulting in a range of predominately cool-toned colours (such as blues and greens) to choose from. I experimented with different colour variations of blue and green with viewers with different visual abilities [37, 38]. This involved testing combinations for contrast and visibility, as well as considering the use of colour in different types of media, such as print or digital interfaces [39].

Referencing these colours to relevant research revealed that both blue and green are perceived as emotionally calming, soothing, and encourage logical thought [31, 33, 35]. Each colour has a neutral causation across cultural and religious resonance, making them a culturally appropriate choice for the poster background [28, 35]. The use of such bold contrasting colours not only fits in with the QH design trends, but the tonal qualities work to strengthen a sense of the authoritative importance of the poster’s overall message.

As a result of this research and testing, a dark blue was chosen for the background, complemented by a striking light green to frame the boxes to create a focal point for the illustrative aspect of the poster design (see first row of Fig. 2—bottom image).

Taking a more conscious approach to the colour selection of the individuals depicted, my attention now shifted towards resolving the bias towards a use of Caucasian figures in medical illustrations, and addressing the lack of inclusivity among the LGBTQI+ community [14, 15]. Referencing existing knowledge of cross-cultural colour theory within the socio-political space of gender and sex, I made the deliberate choice to use an unnatural skin tone to represent the human figures within the steps. Removing the complex symbolisms of the human body does not negate the importance of individual culture and race, but rather its intention is to create a sense of inclusivity for all by using a neutral colour [14].

I investigated a range of colours that complemented the main colour palette, ultimately choosing a cool-toned dark purple hue with low saturation for its perceived passivity and neutrality [35]. A lighter purple in the same hue was used to fill the figures, while the darker purple was used to outline (see second row of Fig. 2—bottom image).

Adhering to the design intentions I had set out, a cool-toned grey that met the same light and dark colour values of the purple that was used to depict clothing within each figure (see second row of Fig. 2—bottom image). The psychology of the colour purple suggests that it can be both contrastingly calming or stimulating to a viewer, while grey was widely regarded as lacking emotion, making them both a versatile colour in design [33, 35].

Through the final stages of prototyping and testing, some refinements were made at the request of the PROV-ED team. It was at this stage that four colours were added to clarify the two adjacent boxes for each sex. Due to project workloads within the QUT Design Lab, this task was given to another designer within our team. They have chosen the four colours as complimentary to the original palette (see third row of Fig. 2—bottom image).

The carefully curated colour palette seamlessly fits into the realm of the existing QLD Health directives, and aligns with recent studies into the colour preferences of those from different age groups, genders, ethnicities, and cultural and religious differences [34, 40].

The additional colours used within the illustrated steps were chosen exclusively to provide an accurate depiction of the object a person would engage within the ED. For example, the lid of the urine collection container is yellow, while the colour red is used as a directive to follow, along with any additional information needed to be communicated within a step. All of these colour choices were made to reflect the form and function of the ED space, to assist users of all cultural and literacy abilities [11].

11 Illustration and Iconography

This project provided a very important opportunity to address the discourse of inclusivity, equity and access within the healthcare sector, by adopting a stance of awareness. To meet the challenges of reducing the confrontational nature of the previous graphics, a gestural drawing methodology was adopted (see Fig. 3). Gestural drawing as an illustrative technique today is used in art to capture the basic movement and energy of a subject with loose, fluid lines [41].

Fig. 3

Adapted from “Amedeo Modigliani, Caryatid, c. 1913– 14, p.” (Fig. 3.4). In P. Crowther. (2017). What Drawing and Painting Really Mean: The Phenomenology of Image and Gesture, p. 56

Like colour, image is interpreted based on the viewer’s own experiences; this space for imagination and interpretation within the gestural drawing approach generates a rich space for each person to see themselves represented in what is not left on paper [42]. This gestural drawing practice provides that freedom to illustrate each step without depictions of genitalia, while still creating the same narrative function of each movement and action.

For the female-presenting figure, the results were achieved by colouring the entire figure in one block colour and adding further detail in the arms and legs—doing so shifted the focus away from the genitals. With a similar approach, the male- presenting figure was carefully angled to minimise the details seen around the genital area and shift the attention towards the details of hand placement and correct technique of collecting the urine (see Fig. 4).

Fig. 4

Final poster

These illustrations went through various phases of refinements based upon feedback from peers, and in consultation with the PROV-ED team to ensure that each figure conveyed an accurate portrayal of each step. The separation of action and deliberate perceived stillness of the body (and not the face) depicted in each step eliminates the problematic connotations of sexual anatomy and cultural and religious sensitivity, while still providing adequate context. Guided by the simplified text generated by the PROV-ED team, I have been able to re-draw the line for heteronormative symbolism of the human form [13, 26, 43].

12 The Final Poster

The design went through multiple rounds of iterative feedback sessions with the PROV-ED team regarding the illustrations, the number of steps, layout, and the narration style to ensure that it effectively communicated the intended message.

The final poster design (Fig. 4) was completed and displayed as repositionable A3 vinyl posters in ED toilets at a pilot site within PAH ED for a trial period. The completion of this project proved to be successful, and the posters are now being implemented across all Queensland Health EDs.